2016 Tax Year: You should complete this form after you have received a bill or notice from the Department

RO-1033

3-15

Installment Agreement Request

North Carolina Department
of Revenue

Individual's First Name

M.I.

Individual's Last Name

Individual's Social Security Number

XXX-XX-

Spouse's First Name (if joint liability)

M.I.

Spouse's Last Name (if joint liability)

Spouse's Social Security Number (if joint liability)

XXX-XX-

Entity's Legal Name (if Corporate)

Federal Employer ID Number

XX-XXX

Daytime Telephone Number (Include area code)

Home Telephone Number (Include area code)

If Joint Spouse's Telephone Number

Address

County (Enter the first five letters)

City

State

Zip Code

Country (If not U.S.)

Part 1.
Installment Request

1. Enter total account balance for all periods

1.

2. Enter installment amount

2.

3. Enter first installment date

3.

(MM-DD-YYYY)(date should be between 1 and 28 of the month)

4. Payment Frequency

If date falls on weekend or holiday, the transfer will occur on the next business day.

Monthly

Weekly (Please select corresponding day.

2 x Month (1st and 15th ONLY)

Day must correspond with the first installment date.)

Part 2. Bank Account Information (Approved agreements
must be paid in monthly or semimonthly installments by direct transfer from your bank account.)

5. Financial Institution Name

6. Account Type

7. Transit or Routing Number

8. Bank Account Number

Personal Checking

Personal Savings

Business Checking

Business Savings

Part 3. Authorized Signature (The Installment Agreement must be signed by the taxpayer or an individual authorized to act on behalf of the taxpayer.
Generally this is the person with the authority to sign a tax return.
)

I certify that I have the authority to request an electronic debit from the account named above, and I authorize the N.C. Department of Revenue to present debit entries for the bank
account and the financial institution named above. This authorization will remain in effect until the balance due has been paid, the N.C. Department of Revenue cancels the installment
agreement, or a written notification from the taxpayer to stop the debit transactions has been received and processed. The N.C. Department of Revenue may cancel the installment
agreement and charge the taxpayer a dishonored payment penalty and a collection fee if the monthly payment cannot be deducted due to insufficient funds or because the account is
closed. The taxpayer will be responsible for any overdraft fees charged by the bank.

If this request is accepted by the N.C. Department of Revenue and an installment agreement is established, the following conditions apply: The agreement is based on the taxpayer's
current financial circumstances and is subject to revision or termination if subsequent financial information required by the N.C. Department of Revenue reflects a change in the taxpayer's
ability to pay. Failure to provide updated financial information when requested by the N.C. Department of Revenue will be reason for termination of the agreement. All State taxes and
all State returns that become due during the term of the agreement must be filed on time. Any State and Federal refunds that might otherwise be due may be applied to this liability until
it is satisfied. If the conditions of the installment agreement are not met, it will be terminated, and the entire tax liability will be due. The agreement may be terminated if collection of the
tax liability is in jeopardy. This request may require managerial approval: you will be notified if it is not approved. If you are granted an installment agreement and subsequently default
on that agreement, you will NOT be eligible for another installment agreement with the N.C. Department of Revenue.

By submitting this form, I hereby certify that, to the best of my knowledge, this
form is accurate and complete.

Print Name

Title (if business)

Date (MM-DD-YYYY)

If you have any questions about your installment agreement request, call toll free 1 (877) 252-3052. An interactive Voice
Response System is available at all times. Our representatives are available weekdays from 8:00 a.m. to 5:00 p.m.